Utilization Management Nurse, Senior

About the role

The Utilization Management team independently manages complex utilization and retrospective clinical reviews across multiple lines of business, assessing medical necessity, coding accuracy, treatment plans, discharge planning, and compliance requirements while supporting clinical consistency, process improvement, quality, timeliness, and appropriate escalation of high-risk cases.

Responsibilities

• Independently manages complex prospective, concurrent, and retrospective utilization reviews across multiple lines of business
• Conducts retrospective clinical reviews of claims for medical necessity, coding accuracy, medical policy, and contract compliance
• Serves as a clinical subject matter resource to peers by providing guidance on criteria application, documentation, and processes
• Evaluates treatment plans, lengths of stay, and discharge planning to ensure quality, cost effective utilization of services
• Identifies overpayment, third party liability, and coordination of benefits opportunities and initiates appropriate follow up
• Supports process improvement efforts to enhance clinical consistency, efficiency, and regulatory compliance
• Escalates complex or high risk cases to leadership or Medical Directors with clear clinical rationale
• Works with minimal supervision while maintaining accountability for quality, accuracy, and timeliness

Qualifications

• Associate Degree in Nursing required
• Bachelor of Science in Nursing or advanced degree is preferred
• 5 years of prior relevant experience managed care environment or clinical setting
• Maintain active, unrestricted RN License in assigned states or the ability to obtain required state (in addition to primary state license)

Skills

Ability to work evenings and weekends as part of rotating on-call schedule

Benefits

Hybrid Virtual Work

Pay

• Pay Range for California: $90860.00 to $136290.00
• Pay Range for Bay Area: $102424.00 to $153636.00

Schedule

Full time

About Us

About Blue Shield of California As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals. Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values

• Honest
• Human
• Courageous

Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility: For most teams, this means coming into the office two days per week. Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need. For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being. The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. Please click here for further physical requirement detail.

Equal Employment Opportunity

All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.